2.0 Analysis 2.1 Effect of Water in the Bilge Because the vessel was lost, the hull could not be examined and because no construction plans were available, the dimensions of the engine compartment could not be verified. Consequently, the quantity, and the trimming and free-surface effects of the water in the bilges could not be determined. Free-surface effect of any liquid would have a detrimental effect on the intact stability characteristics of the vessel. However, photographs show that the engine compartment was much smaller than the full width of the well deck and, consequently, free-surface effect would be a relatively minor factor in the event of the engine compartment and/or well deck becoming partially flooded. The predominant effect of the accumulation of water in the engine compartment was to increase the loaded vessel's already marked trim by the stern. The resultant reduced freeboard aft rendered the vessel highly vulnerable to the shipping of water on deck which culminated in her foundering. 2.1.1 Factors Contributing to the Swamping of the Vessel In shallow waters, as a wave approaches, the wavelength becomes shorter. When the depth of the water becomes less than half the wavelength, the crests break and tumble over, forming surf. The WHISKEY JACK was anchored close offshore on the weather side of Fan Island in shallow water and the sea-bed was shelving in the area. These conditions were conducive to the vessel encountering increasingly high waves as the vessel was driven toward the shore. This is consistent with the wave height observed by the crew of the WHISKEY JACK. At the time of the occurrence, the WHISKEY JACK had a low freeboard aft of about 75 mm. When a large wave struck the port quarter of the vessel, sea water was shipped and retained on the afterdeck well, further reducing the already low freeboard aft. Successive large waves swamped the vessel. This additional weight aft caused the vessel to settle rapidly by the stern, downflooding through the open after door. The air in the bow of the vessel provided buoyancy, allowing the bow to remain above the waterline for a short period. Furthermore, as the vessel was at anchor, her ability to respond effectively to any immediate corrective measure would have been restricted, which could have influenced the outcome of this occurrence. 2.2 Confusion Regarding the Distress Situation The CGRS should have known that there were two vessels in distress since it was aware that the names of the distressed vessels (something JACK and PACIFIC PORCUPINE) were distinctly different. Furthermore, the VTC Prince Rupert, the CGRS Prince Rupert and the CCG helicopter had all heard a MAYDAY message on channel 16 and the helicopter had partly identified the name of the vessel as something JACK, whereas only one fishing vessel reported to the CGRS hearing a MAYDAY from the PACIFIC PORCUPINE on channel 68. Also, the WHISKEY JACK had been positively sighted off Fan Island around noon. The fact that the CGRS was unable to determine that two vessels were in distress at about the same time may be attributed to the following coincidences and factors: The two vessels, WHISKEY JACK and PACIFIC PORCUPINE, transmitted MAYDAY messages similar in content almost simultaneously and both vessels were in the same general area. None of the shipboard or shore-based radio stations heard both MAYDAY messages. On the day of the occurrence, no fishing vessel responded to the MAYDAY RELAY from the CGRS requesting information on a distressed vessel whose name began or ended with JACK. All information respecting the distress of the PACIFIC PORCUPINE had been confirmed whereas no information respecting the distress of the WHISKEY JACK could be verified. Neither the CGRS nor the VTC had heard the name of the distressed vessel (WHISKEY JACK) nor was either station able to recover the vessel's identity from the audio recording. Over-reliance was placed on the information presented by the NANI WAHINI in that the loud-and-clear message received by the helicopter CG358 partially identifying the vessel as something JACK and the reported sighting of the WHISKEY JACK off Fan Island around noon did not receive due consideration. The cumulative effect of the above resulted in the CGRS erroneously concluding that only one vessel, the PACIFIC PORCUPINE, was in distress. Consequently, no further action was taken until the WHISKEY JACK was reported missing the following morning. Since the interference in communication and the reported degradation in audio quality could materially detract from the optimal performance by the CGRS operators, the overall evidence suggests that appropriate weight was not assigned to important cues. 2.3 Safety Equipment Issues As the vessel was not required to carry an EPIRB, the only method of alerting the authorities available to the crew was the VHF R/T. The rapidity of the swamping and foundering prevented the operator of the WHISKEY JACK from transmitting a complete and detailed MAYDAY message. Thus, vital position information was not available for SAR operations. Further, as the pyrotechnics were no longer accessible when the vessel was swamped, the occupants had to rely on passing traffic for assistance. Their rescue therefore depended upon their success in visually drawing attention. Two of the three crew members of the WHISKEY JACK managed to swim to shore but were unable to summon assistance. The survivors were fortunate in that their absence was noticed by other fishing vessels, resulting in the resumption of the prematurely terminated SAR activity and their eventual rescue. 2.4 Use of Non-approved Marine Equipment - Frequency Scanner As continuous monitoring of channel 16 at sea is mandatory for all vessels required to be fitted with VHF R/T sets, some marine VHF R/T sets available on the market incorporate a scanning feature with channel 16 override. The equipment aboard the NANI WAHINI was not provided with such an override feature. As the distress broadcast on channel 16 had not been received aboard the NANI WAHINI, it would suggest that channel 16 was not effectively monitored. In this instance, the use of a non-marine scanner resulted in the NANI WAHINI reporting to the CGRS that the PACIFIC PORCUPINE was in distress, not the WHISKEY JACK. Thus, the attention of the CGRS was diverted from the primary distress situation involving the WHISKEY JACK broadcast on channel 16 to the already resolved distress situation involving the PACIFIC PORCUPINE broadcast on channel 68. 3.0 Conclusions 3.1 Findings There are no design and construction standards for a vessel of the size and type of the WHISKEY JACK, nor was the vessel required to be inspected. The vessel had undergone several modifications and was utilized in an industry for which she was not originally designed. While the vessel was engaged in harvesting sea urchins, sea water accumulated in the engine compartment, disabling the vessel's hydraulics. The loss of mechanical hoisting prolonged the loading of the catch in worsening weather conditions. Two bilge pumps to the engine compartment were not reconnected following repairs to the main engine. The moderate to large swell in the area was attributable to location, prevalent weather conditions and the shallow water effect. The open construction of the vessel, the low freeboard aft and the presence of swell on the vessel's quarter permitted a large quantity of water to be shipped and retained in the afterdeck well. Quick succession of moderate to large swells caused the vessel to settle rapidly by the stern and founder. The rapidity of the swamping and foundering of the vessel precluded the operator of the WHISKEY JACK from transmitting a full MAYDAY message and severed the only communication link. The Coast Guard Radio Station (CGRS) and the Vessel Traffic Centre (VTC) Prince Rupert did not hear the name of the distressed vessel (WHISKEY JACK) in the MAYDAY broadcast nor were they able to retrieve this information from the audio recording. The two vessels in distress in the same general area broadcast MAYDAY messages similar in content almost simultaneously: the PACIFIC PORCUPINE on the very high frequency radiotelephone (VHF R/T) channel 68 and the WHISKEY JACK on channel 16. The MAYDAY transmission from the PACIFIC PORCUPINE was picked up by the frequency scanner aboard the NANI WAHINI, but the MAYDAY transmission from the WHISKEY JACK was not. The attention of the CGRS was diverted from the primary distress situation involving the WHISKEY JACK. The similar content of the two MAYDAY messages, certain coincidences, the account by various participants in the distress-related communications and the lack of appreciation of important cues resulted in the CGRS erroneously concluding that only one vessel, the PACIFIC PORCUPINE, was in distress. This erroneous conclusion resulted in the premature termination of Search and Rescue (SAR) activity, therefore delaying the rescue of the crew of the WHISKEY JACK. The radio equipment of the CGRS Prince Rupert periodically experiences overriding of simultaneous calls and audio degradation of the received signals such that the message is indiscernible. Valuable information which would have confirmed the WHISKEY JACK distress was not volunteered on the first day of the occurrence by fishing vessels that had heard the MAYDAY transmission from the distressed vessel, nor did they respond to the MAYDAY RELAY. The Rescue Co-ordination Centre (RCC) Victoria was advised by the CGRS of the distress situation involving the PACIFIC PORCUPINE; no reference was made to the MAYDAY message transmitted by the something JACK. The rapidity of the swamping and foundering of the vessel precluded access to life- saving equipment and pyrotechnics. The crew swam to shore for fear of being stranded on the reef in darkness. The current carried the diver parallel to the coast and he was unable to reach the shore. The diver succumbed to hypothermia and drowned. The two survivors, when rescued some 16 hours after the foundering, were suffering from hypothermia. Alternate sharing of the dry-suit by the two survivors was instrumental in saving their lives. There is no regulatory requirement to provide thermal protection equipment for fishing vessels of this size. 3.2 Causes The heavily laden WHISKEY JACK was swamped by successive large waves and foundered. Valuable time was lost because the Search and Rescue (SAR) initiative was prematurely terminated at the communication stage as a result of confusion regarding the identity of the vessel in distress. This confusion arose from the fact that two vessels had transmitted similar MAYDAY messages almost simultaneously. 4.0 Safety Action 4.1 Action Taken 4.1.1 Sail Plans for Effective Search and Rescue Each year, several vessels are reported overdue and lost at sea. The failure to complete and file a sail plan or to maintain a proper radio contact has accounted for several losses of life. A recurring problem encountered by Search and Rescue (SAR) units is the difficulty in determining where to initiate searches. As a result, valuable time is lost. Sail plans can reduce the SAR response time when vessels cannot be contacted or are overdue at destination. In 1994, as a result of a series of marine occurrences involving charter vessels, the Board made a recommendation (M94-04, issued in February 1994) on the importance of establishing sail plans for effective SAR operation. Subsequently, the Canadian Coast Guard (CCG) issued Ship Safety Bulletin (SSB) No. 4/95, Recommended Safety Communication Measures for Small Craft. The SSB is directed at operators of small craft, including fishing vessels, and outlines sail plan procedures, sail plan processing, and alerting services provided by the CCG.